commissions as votes are taken and i would therefore, make this a motion, so that we could move forward. and we have already had the discussion, to vote and now we will close it for the next part and that will be my motion. >> and do you... >> yes, is the motion is that we then make the election all of that, and at this point, the commissioner votes that it be logged as you nan maous and move forward. >> is there a second to that motion? >> not hearing a second to the motion, the motion will die at this point. >> okay. >> yes. >> and i just want to make a comment and i think that i really appreciate the level of expertise, commissioners each bring to this commission and i certainly have learned a lot.

and i think that another things that i really appreciate and it is a practice that i actually did as well, and during my years and it is shared leadership and it is often encouraged and so, it is not like we have elected one commissioner that is going to like stay on the leadership positions forever, i think that has been rotating and it has been rotating process, and i say that that is something that public should know as well. and so, this way we can really meet the need that the health department currently needs. and also, give everyone an opportunity in the future. you know, to fill these opportunities and much needed responsibilities. >> okay. >> yes, i thank you

commissioner and i remind everybody that every commissioner is equal, in regards to whether they are an officer or not. and as a matter of fact, we serve at the pleasure, of the commissioners. and that no one single commissioner actually makes the decision, the decisions are made by the commission as a whole. and, personally, i would like to thank commissioner taylor-mcghee for the work that she has taken on. and we spoke about that, at the time, when i was looking for various positions and i think that it is most come mendable, and i know that she will continue to give every effort to not only the african american initiative, but all of the work that she does, on behalf of our commission for the health of the city. including of being at our san francisco health plan. so, again, our thanks and i agree that the votes, do not

reflect that we are not in harmony. what they do reflect is differences in emphasis on how one might wish to look at those who are helping with our commission, and i view it in that manner. and i am hoping that everybody else will view it in the same way. >> are there any further comments? >> if not, then, let us proceed to the next item. >> yes, thank you, commissioners item 8 is a revised san francisco general hospital, staff bylaws, dr. marks is here to present. >> the memo in the packets, commissioners that he will review and the summary of the changes. >> good afternoon, commissioners president, and the two of you that i have not met yet, i am jim marks and i am chief of the medical staff, at san francisco general hospital. and you have before you, the

revisions to our by laws and our rules, and regulations, which i think that are about 150 pages. and these have been approved by our credentials committee and medical executive committee and joint conference committee are now before you. and there is a simpler two-page summary that highlights the changes, and rather than go through that, i will just kind of bucket them into three groups that i will briefly describe. one of them are those that address the increased accountability of the medical staff, and clearly defining, the requirements around the board certification and the dea certificate identification, and completing of the hospital orientation and other regulatory requirements and attendance, and committees, and etc.. and the other such big group of changes are just, updating for example, and committees structures and committee and new committees that have come and the old committees that

have left, and then the third big area is really the elimination of probably more formal language for what i would just call, more simple speak, and that is very clear. and so, i am very happy to take any questions that you have about the changes. >> and if i may, to the san francisco general hospital, jcc has reviewed these and then forward them for your recommendation, and for your approval. >> okay, so these specific are before us as business from the jcc. and were there any public comments? >> i have not received any public comment requests for this item. >> commissioners the item is before you, discussion is in order. >> i would move approval. and also congratulations our medical officer who did a fantastic job of the staff and it was presented and great detail, twice, and before the jcc for discussion, and for the peer review and so i would move and. >> thank you, commissioner. >> okay. >> yes, please? >> parks, thank you very much,

for the wond bylaws that made good nighttime reading >> help with the sleep and i am sorry, we got this and to be in the hr and really important because they also relate to health, equality andvy 10.13, the medical staff and xwhitties and in the revision you limited the well-being committee to working with the medical staff and so i just want to ask you are the residents, and then the anxillary staff that are rotating through campus, can they access the well-being, eep services as well? and it sounds like it is a broader scope there and a broader function. good, the last thing is item 12.2-2, disclosure confidencal information and so i am really in favor of, you know, when there is a position with an impairment or a safety issue that there is broad notice to make the system safer, and on the other hand we have to

balance it with what is confidencal employment and hr related privacy issues for the particular physician or the staff employee. and so this one, asks that on the initiation of a corrective action, and you could then, notify, the health network and i just was thinking of well, there is not really an action there and it is sort of like a suspicious and i am just a little worried because of the way that a lot of reporting has been going to the state level and we are being increasingly to support the suspicion which are not quite, actionable yet and i just want to make sure that the due process is involved before there is a breach of confidentiality and there might be, employment related risks there and so, yeah. >> and yes, i don't recall all of the discussion on there, but cathy murphy, the city attorney served on the bylaws committee and we certainly, considered that and we had her input as you know, the trade off in informing the network and

confidencalty. >> yeah. >> i guess that if you could reassure me that if there is a process there, that there is either a scrutiny, and the executive level of the safety concern and a warning and alert. and i will feel satisfied and just to have a suspicious and then it goes across the system, and it crosses kind of... >> perhaps i could help with this one, because i know where this came from. and which is that if in fact an issue came that needed to be reported is basically an action, and organizations within the organization within the health network, we actually only have two credentially organizations but as sf general or laguna honda which is all of our services all are through san francisco general and so, if, if somebody in fact also

has privileges at the other hospitals, this is the only one. >> the issue is that the other hospital should be aware of it. >> yeah. >> normally, we will have, combined the two facilities, for many reasons, they each have a different license. and this is the reason for sharing, the peer review. and for sharing, the suspicious if you wish to call it. and in fact it is gone beyond a suspicious and the sense that it is a (inaudible) report and it is the initiation of the investigation and the 805 is actually an action and we got to meet the restriction and things like that and i am okay with your assurance that there is a good review before there is..., and i can assure you have tha. >> and there it is for only going to the laguna honda, medical staff and, that that is the effectiveness of this. >> and commissioner, this was an incident that we had where we had a... working and if

order for us to have a common reflection of their work from a network perspective that this was... attempt to do it. >> these are really subtle issues and we correct it, and director garcia and this was, a specific instance and this was very, carefully considered and it this was the appropriate way to manage it going forward and we want to be sure that we (inaudible). >> yeah, from the commission, standpoint, we are involved as governors of both organization and it would be unusual that if we were notified of the corrective action or initiation in one area, but we could not let our sister institution for which you are responsible know about it also, and like say general and so it is like, the network of hospitals, and that we need to see that the peer review information is able to be transferred to the other if,

in fact, it is the same practitioner who is practicing and so how could we then, and how we are going to let the other people know that there was a question and but that there is a question in the case of a correcter action and it is up to the other institution and the people does it effect, what we are doing here? >> if you can work it, and when you are not able to pass it over, and then we are sitting as the governor ans and we know it over here, and we can't do anything over there. at least, leave it to inquirery. and that is >> thank you very much. >> directors? >> yeah, normally. back in the motion to approve and congratulate dr. marks and quite an extensive team of his that is extensive in terms of the positions and staff members and hours for the end, and

making sure that and that the bylaws sit with the best practice and in the year 2014. that is right, foyer got to accept the second. >> and any further discussions or if not, then we are prepared for the vote. >> and all of those in favor of accepting the revisions to the bylaws and regulations aye. >> aye. >> all of those opposes? the ayes have pass and so has the buy laws revisions and many rules of regulations, and thank you very much, dr. marks and please convey our thanks to the entire bi laws and that feels good after a year plus. >> thank you. >> and commissioners the next item is the healthcare accountability ordinance and the resolution. >> give me just one second. >> we will go back.

>> all right, well good afternoon, commissioners and thank you so much for the opportunity to speak with you today, and i am francis culp and i am a senior planner with the office of policy and planning here at dph. and we are going to talk about the healthcare accountability ordinance, minimum standards and review process that we went through and the recommendations that we are bringing to you and you will have in your packet a report that was written on the process and the recommendations that have two attachments one is a table with the recommendations, and one is the resolution that will be asking you to vote on today. >> the healthcare

accountability ordinance or hcao, was a ground breaking and innovative piece of legislation that was passed in san francisco, by the board of supervisors, and in 2001, and as part of the minimum compensation, ordinance and that, that whole package of changes, and what it brings to the city is a pathway for more people in our city to have employer-based health insurance, and the minimum standards help to make sure that that employer based health insurance is meaningful insurance, and so, they are not under insured as well. and so, when it is the effective date on it was july first, 2001, after it passed earlier in the year. and the covered, and those who have to have to work with the hcao, are employers who are working with the city, and to either a contract, or a (inaudible) and there are

certain exceptions that employers can get and those are detailed more in your report. but, most employers working with the city have to provide a health insurance that meets the minimum standards they have another option. that option is to pay a fee to the department of public health to offset the cost of of providing care to the uninsured the care fee changes from year to year it is at $4.25 per hour, for a maximum of $170 per week. >> and that is actually based on hmo premiums and the coast of hmo premiums and i believe that many people prefer this, including the employers to offer the insurance, rather than paying the fee and so what we want to do is price, the fee, to be with the cost of health insurance and we don't want it to be a better deal,

but then to actually pay the fee. and so we work with the controller's office every year, to update that amount. >> and at any rate, with the minimum standards, we are asked for the ordinance to look at them, and once every two years, and review them and revise them if necessary and since we have been doing this back in 2003, we have actually found that it is always necessary to make some changes. and the health insurance, market is extremely volatile, and really there is no sign of that, getting any better, and last time that we reviewed and there is a lot of change and volatilety in the market and what is offered and what kind of packages are offered for the employers to purchase for their employees. and so we really have to tweet the minimum standards to make sure that the employer can actually buy plans that will then work with the minimum stan aders or they are forced into

paying the fee. >> the health department's role is to do the review and recommend the revisions that how the commissions roll is their sole role is to vote on the revisions and the recommendations that we make to you, or ask for the changes or whatnot. >> and so, starting back in 2003, when we did the first, and when we came first to the health commission and with the changes, and we had not actually used a stake holder process and we did it intinally and at that point, the health commission asked us to go back and work with the stake holders from the people that koim ko the meeting and asked if they could be part of the process and so ever since that time, based on what the health commission instructed us to do, and we have use aid stake holder process, where we have interested parties from a variety of different perspectives that help us to review the minimum standards and advise us on recommendations, and that they are interested in seeing, and we try to really work on it, on

the process and we have 14 organizations this year that we worked with, and non-profit and forprofit employers and labor representatives and brokers and health plans and other city and council san francisco departments and i should mention that the departments in the city that actually does everything else with the hcao, and does the auditing and making sure that the employers are doing what they are supposed to do is the office of labor standards and enforcement and so we work very closely with the olsc and they were involved in this as well. and we have 6 meetings and we originally thought that we would do four. but it turned out that we needed to add a couple on, because we honestly sort of under estimated what the affordable care act, and how much it would prove and... (inaudible) in the situation and we ended up having a lot more educational time in the beginning and even some of the brokers there were kind of grappling with the questions

that they had in not grapled with yet and so it was a to take on and so the group was actually nice enough to come a few extra times to the meeting and the goals were simple and at least straight forward i should say that they were to for the group and they were asked to help us to develop these recommendations that would be in place for january first, 2015. and also, to balance affordability and availability of health plans that will be under the minimum stan ard and that is really on the both sides and the employer and employees we want to be sure has choice in this whole structure. and so, really quickly, and i don't want to spend too much time on this because i am sure that you quite familiar but to be sure that we are on the same page as i talk more about the insurance details that i have

done a quick glossary for you and i will start with the co-insurance and we will be talking about these things more later, the co-insurance is the percentage of the charge of the medical care that you would share with the insurers and so 100 dollar visit if you got a 20 percent co-insurance, and you paid, 20 dollars and the insurer pays 80 and the provider gets paid, the detukt able is the amount that you are paying in full for a service, and until you hit that deductible amount and then you start paying the co-pays, and the co-insurance, amounts, and whatever your particular plan requires of you. and so you are paying that $100 visit in full until you have enough visit and that deductible kicks in, the out of pocket maximum is the amount that you can or would pay up to in a year, and that then, it would be for the insured

person, and they would be responsible for no other cost, so, this is a really for the people with and who have catastrophic incidents and the costs go high and at that point, they are no longer responsible and the insurance takes over 100 percent. >> and a couple of other terms that we will be talking about today are the health reimbursement accounts and the health savings accounts and these became part of the option and part of the minimum standards a couple of years ago and as you will see, we are continuing with that. and as you can see the fee there, they are both different kinds of accounts that the insurered person can access, to pay, or to pay part of their cost associated with the insurance. and what this does in the minimum standards, is that it gives the employer, if the minimum standards and these minimum standards have to last two years, even as the market changes and so in case, the

employer for whatever reason or reasons, is really having a struggle finding a health plan, and maybe it is just a one thing, and it is the out of pocket maximum that is $500 too high. and for what we say that the minimum standards have to be and then the employers can get a $500, dollar, hra or hsa and pay for it that way, and on behalf of the employee and the main question that we asked around that a lot and really made sure was that a burden on the employee could be the employee be caught with the special cost that we don't know about, and could the employees, healthcare privacy be in any way, lost in that exchange, and we felt very, very, certain at the end of it, that this was a fair and good idea. and to keep these minimum standards, but just want to talk more about that later, just want to make sure that we have got some definitions of

these terms. so, this gives you just the high points of the current minimum standards and you will see more in detail in your report, there is a table, that shows the old minimum standards but these are kind of the big picture and the big ticket items in any health plan and so, the minimum standards do include the premium cost and who pays the premium. and the minimum standards have always required that the employer pay 100 percent, of the premium costs. and the employee pays zero. and the out of pocket max was presently today, and it was a current minimum standard is $4,000, and it must include all types of cost sharing and that means. the deductible and really anything that that employee is putting toward their healthcare. >> and the deductible maximum is $2,000.

and the hsa, hra account is load and in relation to the medical deductible only. and go insurance, if there is go insurance in the plan, is the most the employee can be required is 20 percent, in network. and 50 percent out of network. and the co-payment is at $30, in that network, for provider visits like primary care and things like that. and of course the preventive care we know is free. >> so now i am going to get into the recommendations, and i am going to grab my water and, my throat is really dry and so if you can excuse me. for one second. i am so sorry. >> thank you. >> so the first recommendation that i want to share with you is one that is sort of just a housekeeping one more than anything. and the affordable care act, of

course, i am sure that you have heard quite a bit about the ten essential health benefits and i will ask you to disregard the pediatric one, and the services would not be included in this because i have not mentioned this yet. but the minimum standards do not cover the dependant care we will talk more about that but they traditionally have not and still do not. >> and so, but all of the other ten benefits what we wanted to do was align the current minimum standards the way that they are shown and discussed and the language used around them is now matching, with the ten essential health benefit and then for the actual really sort of nitty gr. ritty of the detail, i am the one in the department that will get the calls from the employers who are saying that i am looking at this plan and do i have to cover this thing, or that thing? and so, i now, i will be able to look it up, on the covered

california bench mark plan which then, as what they do is they have to take the ten essential health benefit and then take a plan that is in the coverage california, network of plans, and select, one that shows to the great detail, what must be covered and what does not have to be covered. and so, that allows myself, and anyone else to look at the website, and see an old, and a list of benefits that, will always be very accessible on-line and so we have more information on out there and it makes the things quite a bit easier from what we have done before because it is hard to list every single thing and there are issues of interpretation and that that is really improved by doing it this way and we lost nothing, and i talked about more in this report and there is nothing that is not covered under this recommendation, that was cover

befored. and if anything, there may be more things covered. particularly with the new language around sort of the rehab taiive services that the people are sort of defining and california has a very broad and ininclusive definition of. so that is our first recommendation. the second one is around dependent coverage and what happened this time around was that there was interest on and among several of the work group members, to cover dependents and that has come up some years ago. and it sort of it is something that we have explored and just a bit here and there and given all that we had to deal with, the group had a consensus around this decision to wait two years and give the health department time to really explore this option and see how we can bring the dependant coverage into the minimum stan aders and that is not something

that we have done before and so it will give us time to share with the advisory group, kind of the pros and cons, and the ideas of how it can be done, and that kind of thing. so we are just deferring that to 2016, but we did promise the group that we will put this up front to the health commission and make a promise around that in writing. >> recommendation number three, is around the hra and hsa options and so, what we have done here, and this is something that also, the group agreed on, fully, is that we will allow hsas and hras to be used in case of not just a medical detuktable but also out of pocket maximums and so the employer has a little more flexibility around choosing a plan, that may have a higher out of pocket kind of like i described before. and they could secure that plan, and it would be paid through this account, on behalf of the employee and the funding

would come from the employer, and be fully employer funded. the next one is something that when we went in to the advisory group, i think that we thought a lot about tying it to a tier and we would say, well, maybe we will just say that the minimum standards are tied directly to the goal plan, or the silver plan and that was something that was talked about with the health commission, two years ago in a colleague of mine brought this report to the commissioners. and you know, we kind of actually realized pretty early on that with the group, that it was a lot more complex than we had sought given the fact that these plans rely on the actual value and, what the actual value does, and it says, kind

of the, and it allows you to see that as the cost sharing, between the employee, and the insurance company, and in broad terms and it sort of put a number on that and in each tier has a actual value amount, and i am sure that have you heard about that in other contexts, but what we worry about that was that it could really plans could really put a lot of highs sort of up front costs of a lot of high costs on things like your provider visit and while tweaking other areas, and that was not something that the really the employees or the people representing the employees or the people representing the employers were comfortable and they just offered, too much, variation and thought that it could cost, out some of the employees that would be needing, you know, sort of a basic, plans, but could not afford it because we have a lot of low wage workers in these jobs. and honestly it